A Hybrid Model combining On-site & Remote Video Consultation for Rural Rheumatology

A Hybrid Model combining On-site & Remote Video Consultation for Rural Rheumatology

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Posted on: 08-16-2012 by: Dr Irwin Lim

By Dr Irwin Lim, Rheumatologist

I previously blogged about trying to provide video consultation services (telehealth), to try and bridge the tyranny of distance for rheumatology patients in rural and regional Australia. The overwhelming majority of Australian rheumatologists work in a metropolitan setting. We realise the need to deliver services to the “bush” but we already have a stretched workforce.

Herman Lau & I have been performing video consultation services with Dr Ash Collins, a GP in Temora (418km away) and his patients. This seems a useful service but for us rheumatologists, there is a major downside.

The lack of touch. The lack of being able to physically examine the patient does play on our minds.

To try and solve this, we decided to provide a fly-in service to Temora. Once every 3 months, Herman & I would run a rheumatology clinic at Temora Medical Centre over 2 days.

We plan to see new patients in the flesh with follow up consultations performed remotely via video consultation. If our patients require face-to-face consultation, especially when we need to examine them ourselves, we can see the patient at our next visit.

We’re in Temora now, at our 1st clinic. It’s about half full and that was good, as we wanted time to adjust and make sure that our processes worked.

I thought it would be good to share with you a summary of our 2 days:

- Door-to-door, including the 1 hour flight to the regional centre, Wagga Wagga, followed by hiring a car, took 4.5 hours

- While I was buying lunch at the local sandwich shop, I was complimented. When I told the shopkeeper that I was at the medical centre, he enquired if I was training to be a doctor.

- Computer issues for Herman. While we could easily access our medical software/database in Sydney to consult remotely in Temora, he couldn’t get the printer & his speech dictation system to work.

- We saw some lovely, friendly patients. Some who were very impaired by their rheumatic disease. We instituted some treatment, arranged some investigations and will follow-up most in a few weeks via video consultation.

- There were 2 medical students on their rural rotations who sat in with us. This was an unexpected bonus & it was lovely to be able to teach rheumatology to a new generation (rheumatology teaching is unfortunately very under-resourced at undergraduate level).

- At the end of the long day, we had dinners at Diner’s Choice, a nice restaurant attached to the local bowling club. Portions are huge by Sydney standards.

- It was then off to Koreela Park Motor Inn, to catch up on daily paperwork, before a restful night.

- The next morning, I was interviewed by Prime 7, a regional TV station.

- We then saw more patients, I drained a swollen knee, and I used my portable ultrasound machine to scan a number of joints.

- After a quick lunch, we visited the local attraction, Temora Aviation Museum, for about half an hour before heading home to Sydney. Another 4.5 hour journey.

It’s important to realise that an important issue affecting the long term viability of this sort of service, is the financial loss and time cost of being away from home/family.

We were only about half-full with patients this 1st visit, and the total billings did cover the significant costs involved with traveling, the facility hire fees and our ongoing costs for our Sydney practice while we were away. However, both Herman & I had to be prepared to give up the usual income we would generate seeing patients in Sydney.

This is an important consideration for any rheumatologist considering providing an on-site service to rural & regional Australia. The more often you travel, the more it will cost. A lot of goodwill is required in the absence of any other funding or support to try and help establish these sorts of services. Such funding is in short supply.

All-in-all, I think we accomplished quite a bit. We’ve set in train a possible model to try and help the situation for patients living in rural settings.

Please share any thoughts or relevant experiences you may have.
For those of you overseas, are there similar models you are aware of?

Arthritis requires an integrated approach. We call this, Connected Care.

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  • http://www.ronankavanagh.ie Ronan Kavanagh

    Well done Irwin. How wonderful to be at the cutting edge of something so exciting. It’s always nice to mix it up a bit in clinical practice too and a change of environment can make you think differently. I’d be very interested to hear baout how the video consultations go once you’ve done a good few. I found the first few I did a little stilted and I think I missed some of the visual cues that we all use without thinking in clinical practice. Good to see the locals picked up on your youthful looks too.

  • http://bjcconnectedcare.com Irwin Lim

    Thanks Ronan. I’ve already been using video consultation once or twice a fortnight for the past year. It’s great for follow-ups, for eg, explaining blood test results. In Australia, due to Govt incentives, the video consultations are often performed with the GP together with the patient on the other end.

    However, I don’t feel quite as comfortable with new patients. It’s nice to meet someone for those visual cues you mentioned & also to have the chance to examine them.

  • Jeanette

    I know I have mentioned in the past that my Rheumatologist who is running a one man practice in Regional Victoria would be envious of the services you have access to all in one site in Sydney….so it is good to hear that you have ventured from your state of the art practice to see how the other half live!
    I never cease to be inspired by my own Rheumatologist who travels on a weekly basis to more remote rural areas where patients, many of whom are elderly would not have access to this service…there by comes my question….I know many patients who have done skype consultations with specialists in the city however, how do elderly patients deal with this… if they are not technology savvy enough to set up skype and especially if their GP is not interested in being involved….lets face it in rural and regional country towns GPs are already stretched to the limit and we are crying out for more practitioners because waiting times to see a GP in the country are sometimes 3 weeks. I wonder if there is a place for a rural nurse (or could it even be a lay person?) who could attend the patients residence if they required assistance with the video conference? Just a thought…..

  • http://bjcconnectedcare.com Irwin Lim

    Welcome back, Jeanette. One reason we chose Temora was that they have set us a video consultation facility in the medical centre for their patients. Either the GP or a nurse will facilitate the consultation with the remote specialist. Other “nearby” towns are doing similar, so for the patients you mention, access is still available. In time, local medical divisions may develop such facilities with an allied health support person such as a nurse.

  • Jeanette

    Thanks Irwin….yes I have been MIA having spent 20 of the last 30 days (in two stints) as an inpatient….got me thinking that we definitely need internet access for patients…or at least better mobile coverage at my local hospital :-)

  • Tracy

    It is nice to hear about physicians and medical staff performing what amounts to a partial pro-bono initiative (insofar as you are losing money in this type of endeavor, even if still billing). I have not heard of this being done by rheumatologists anywhere, including in the U.S. I would note, though, that the major tertiary hospital where I receive my care does have a program where it assists patients from afar in making travel plans and finding reasonable accommodations. So at least the hospital tries to help get patients to the treating physicians, even if it doesn’t have a program where physicians travel to their patients. Still, I think most patients would say that, in a perfect world, they would prefer to not have to travel very far at all. The last time I visited the hospital for a follow-up appointment, it was a roughly 3 hour trip there, followed by a 3 hour trip back, for roughly a 20 minute doctor appointment plus some lab work. It left me totally exhausted, but since that hospital is where I have been getting the best care to date on this 3+ year journey, I feel like it is well worth it.
    Dr. Lim, if you are not already doing so, I hope you will consider your work for the Temora patients to be a pro bono initiative, and therefore a worthy investment even if its hurting you somewhat on the business side of your practice. I think pro bono work is the highest compliment a professional can pay to those whom he or she is serving, because you are telling those patients that you think enough of them as fellow human beings to take a financial “hit” to help them, and I don’t think you can put a price on that.

    • http://bjcconnectedcare.com Irwin Lim

      It’s a very salient point, Tracy. Both Dr Herman Lau & I were and are prepared to take some financial hit to maintain this service. The issue will be to try and encourage more and more specialists to do similar. Goodwill is out there. While it’s a little unsavoury to talk about finances, it’s important to minimise the financial loss to reduce this aspect as a deterrent.

  • Julie

    Very interesting to see how this problem of access to care, is being dealt with , in your country, Dr. Lim…

    I would have to agree, though ,that especially the first few appointments, would be best to be seen in person, especially for many rheum patients, where the diagnosis is not clearcut ,and a rheumatologist’s expertise , ie: to check for even subtle synovitis , would be imperative. I know of so many patients, who don’t present as textbook, with the expected labs, etc, and sometimes, it takes careful physician monitoring for developing signs/ symptoms, and rechecking of labs. And I might add, the reassurance from the physician, that he/she will keep working to find the cause of the symptoms, as that is such an important validation, that the patient feels the doc is on the same team as them.

    Welcome back,Jeanette! Please try and stay out of the hospital!! ;)